What is the recommended management approach for hypertension?

Comprehensive Management Approach for Hypertension

The recommended management approach for hypertension should include lifestyle modifications for all patients, with pharmacological therapy initiated for sustained systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg, targeting blood pressure <130/80 mmHg for high-risk patients and <140/90 mmHg for others. 1

Blood Pressure Assessment and Diagnosis

• Follow standardized measurement techniques:

  • Patient seated with arm at heart level
  • Use properly calibrated device with appropriate cuff size
  • Take at least two measurements at each visit
  • Standing measurements for elderly and diabetic patients to detect orthostatic hypotension 2

• Consider ambulatory blood pressure monitoring when:

  • Clinic blood pressure shows unusual variability
  • Hypertension is resistant to treatment
  • Symptoms suggest hypotension
  • Suspected white coat hypertension 2

Risk Assessment

• Estimate 10-year cardiovascular disease risk to guide treatment decisions
• Consider factors that amplify risk:
  • Target organ damage (left ventricular hypertrophy, renal impairment)
  • Established cardiovascular disease
  • Diabetes
  • Family history of cardiovascular disease
  • Age, sex, smoking status, and lipid profile 2

Treatment Thresholds

Immediate Drug Treatment Required:

• Accelerated hypertension (severe hypertension with grade III-IV retinopathy)
• Blood pressure >220/120 mmHg
• Impending complications (TIA, left ventricular failure)
• Sustained systolic BP ≥160 mmHg or diastolic BP ≥100 mmHg 2

Consider Drug Treatment:

• Sustained systolic BP 140-159 mmHg or diastolic BP 90-99 mmHg with:
  • Target organ damage
  • Established cardiovascular disease
  • Diabetes
  • 10-year cardiovascular risk ≥20% 2

Lifestyle Modifications Only (Initially):

• Sustained systolic BP 140-159 mmHg or diastolic BP 90-99 mmHg without additional risk factors
• Trial for 3-6 months before considering pharmacotherapy 2, 3

Lifestyle Modifications

All patients with hypertension or high-normal blood pressure should receive advice on:

1. Weight management: Aim for BMI 20-25 kg/m² (each 1 kg weight loss reduces systolic BP by approximately 1 mmHg) 1

2. Dietary approach:

   • DASH diet (rich in fruits, vegetables, low-fat dairy)
   • Reduce sodium intake (<2,300 mg/day)
   • Increase potassium intake (3,500-5,000 mg/day)
   • Reduce saturated and total fat 1, 3

3. Physical activity:

   • Regular dynamic aerobic exercise (e.g., brisk walking)
   • 30 minutes most days of the week
   • Can reduce resting BP by 3-5 mmHg 1

4. Alcohol moderation:

   • <21 units/week for men
   • <14 units/week for women
   • Include alcohol-free days each week 2

5. Smoking cessation for overall cardiovascular risk reduction 2

Pharmacological Treatment

First-Line Options:

• Thiazide or thiazide-like diuretics
• ACE inhibitors
• Angiotensin receptor blockers (ARBs)
• Calcium channel blockers (CCBs) 1, 4

Treatment Algorithm:

1. Initial monotherapy for mild hypertension with low/moderate cardiovascular risk
2. Initial combination therapy (two drugs at low doses) for:
   • Grade 2-3 hypertension (BP ≥160/100 mmHg)
   • High or very high cardiovascular risk patients 1

Recommended Combinations:

• Thiazide diuretic + ACE inhibitor
• Thiazide diuretic + ARB
• Calcium antagonist + ACE inhibitor
• Calcium antagonist + ARB
• Calcium antagonist + thiazide diuretic 1

Special Considerations:

• ACE inhibitors or ARBs preferred for patients with albuminuria or established coronary artery disease
• Beta-blockers with thiazide diuretics should be avoided in patients with metabolic syndrome or high risk of diabetes
• For adults ≥85 years, a more lenient target (BP <140/90 mmHg) may be appropriate 1

Treatment Targets

• General population: <140/90 mmHg
• High-risk patients (diabetes, renal dysfunction, cardiovascular disease): <130/80 mmHg
• Minimum acceptable control (audit standard): <150/90 mmHg 2, 1

Monitoring and Follow-up

• Monthly follow-up until target BP is achieved
• Home blood pressure monitoring (expected values approximately 10/5 mmHg lower than office readings)
• Monitor for medication adherence and side effects
• Check renal function and potassium within 1-2 weeks of initiating ACE inhibitors and ARBs 1

Common Pitfalls to Avoid

1. Inadequate BP measurement leading to misdiagnosis
2. Overlooking secondary causes of hypertension
3. Medication non-adherence due to complex regimens
4. Ignoring drug interactions (especially NSAIDs)
5. Neglecting orthostatic hypotension in elderly patients 1

BP-lowering drug treatment should be maintained lifelong if well tolerated, even beyond age 85, with regular monitoring and reinforcement of lifestyle modifications 1.